Medical Aspects of Chemical Warfare (2008) - The Black Vault

Vesicantsresurfacing, dermabrasion, and chemical peels. Aninnovative medical device currently available (ReCell,Clinical Cell Culture, Coral Springs, Fla) allows rapidharvesting of cells from a thin split-thickness biopsyfollowed by spray application onto small wounds (upto 2% TBSA) within 30 minutes of collecting the biopsy,without the need of culturing the keratinocytes in aclinical laboratory.Vacuum-Assisted Closure Therapy. Application oftopical negative pressure in the management of chronicwounds and burns has gained popularity in the last5 years. Also known as VAC, the procedure involvesplacing an sterile open cell foam into the wound bed(cut to conform to the shape of the wound), sealing itwith an adhesive drape, and applying subatmosphericpressure (125 mm Hg below ambient) that is transmittedvia an evacuation tube by a vacuum pump. 230,231The procedure is becoming widely used for the closureof chronic wounds such as stage III and IV pressureulcers; venous, arterial, and neuropathic ulcers; andsubacute and acute wounds such as dehisced incisions,split-thickness meshed skin grafts, and muscleflaps. 232,233 This methodology increases local bloodperfusion and nutrient delivery to the wound, acceleratesthe rate of granulation tissue formation, and decreaseswound tissue bacterial levels. 230,231 Before VACapplication wounds must be debrided of all necrotictissue. Contraindications to VAC placement includethe presence of fistulas, osteomyelitis, exposed organs,exposed blood vessels or malignancy in or around thewound. The dressings are typically changed every 1to 4 days until wound closure. VAC has been shownto be effective in preventing progression of partialthicknessburns to a deeper injury in a swine model,likely the result of increased delivery of oxygen andnutrients to the zone of stasis. 232 The method has alsobeen shown to increase the rate of skin graft donor sitereepithelialization in pigs and humans, and it is a safeand effective method for securing split-thickness skingrafts, providing improved graft survival. 233,234 Followingdebridement of partial-thickness HD injuries,VAC may prove efficacious in significantly speedingthe reepithelialization process. Recently the FDA approvedthe use of VAC in treating partial-thicknessburns. Several VAC systems are commercially available,including a lightweight, portable system forambulatory care.EyeThe basic principles of eye care are to prevent infectionand scarring. Although mustard is unlikely toremain in the eye by the time the casualty is seen, theeye should be irrigated to remove any chemical agentthat might be on the lashes and any inflammatorydebris that might be on the surface of the eye. Mildlesions (eg, conjunctivitis) can be treated three to fourtimes daily with a soothing eye solution.Casualties with more severe eye lesions should behospitalized. Care for these patients should consist ofat least one daily irrigation, preferably more, to removeinflammatory debris; administration of a topical antibioticthree to four times daily; and administration of atopical mydriatic (atropine or homatropine) as neededto keep the pupil dilated to prevent later synechiaeformation. Vaseline or a similar material should beapplied to the lid edges to prevent them from adheringto each other; this reduces later scarring and alsokeeps a path open for possible infection to drain. Whenanimals’ eyes were kept tightly closed, a small infectioncould not drain, and a panophthalmitis developed thatperforated and structurally destroyed the eyes. 66Topical analgesics may be used for the initial examination;however, they should rarely be used routinelybecause they can cause accidental corneal damage.Pain should be controlled with systemic analgesics.The benefit of topical steroids is not established inhumans (see experimental animal data discussedbelow); however, most ophthalmologists feel that topicalsteroids may be helpful if used within the first 48hours after exposure. 235 In any case, an ophthalmologistmust be consulted as early as possible. Keepingthe casualty in a dim room or providing sunglassesreduces discomfort from photophobia.The transient loss of vision is usually the result ofedema of the lids and other structures rather thancorneal damage. Medical personnel should assurethe patient that vision will return. Recovery may bewithin days for milder injuries, although those withsevere damage will take approximately a month orlonger to recover.AirwaysThe therapeutic goal for mild airway symptoms(eg, irritation of the throat, nonproductive cough) isto keep the patient comfortable. In a casualty withsevere problems, the goal is to maintain adequateoxygenation.Hypoxia is secondary to abnormalities in ventilationcaused by inflammatory bronchitis. Bronchialmucosal sloughing (pseudomembrane formation)further complicates this abnormality. Bronchospasmis easily triggered, requiring therapy with bronchodilators.Casualties with bronchospasm not respondingto bronchodilators may benefit from steroid treatment,with careful attention to increased risk of infection.Oxygen supplementation may be necessary for pro-287